Note  that I made an edit to this report (March 2023) to highlight that the per person reached cost estimated for DMI includes RCT costs; their per person costs to scale-up a program (aka when an RCT is not being run) are significantly cheaper.  I am looking into this in more detail at present.

Hi Joel, thanks for this detailed + helpful response! To put in context for anyone skimming comments, I found this report fascinating, and I personally think StrongMinds are awesome (and plan to donate there myself).

Yep, my primary concern is that I'm not sure the longterm effects of grief from the loss of a child have been accounted for. I don't have access to the Clark book that I think the 5 year estimate comes from- maybe there is really strong evidence here supporting the 5 year mark (are they estimating for spouse loss in particular?). But 5 years for child loss intuitively seems wrong to me, for a few reasons:

1. Again, idk how good the Clark 5 year finding is so I could be wrong! But the data that I'm aware of suggests that the effect of childhood bereavement is considerably longer than this. Rogers et al (2008) finds that parents still report poorer wellbeing at the 18 year mark, Song et al. (2011) finds that older bereaved couples still had lower quality of lives in their 60s relative to unbereaved couples, etc. From a quick scan (just from looking up 'long term effects child berevement') the estimates that I'm seeing pop up are higher than 5 years.
2. People may develop depression/ anxiety etc in response to the loss of a child. From a quick look (there may well be a better data source than this) there's an NEJM article from Li et al. 2005 that puts the relative risk ratio (for psychiatric hospitalisation, relative to  unbereaved parents) at 1.67. I assume that's going to be a longlasting effect, and I see an argument to 'treat key sources of depression'. 

I do realise there may be confounding variables in the analyses above (aka so they're overestimating grief as a result)- this might be where i'm mistaken. However, this does fit with my general sense that people tend to view the death of a child as being *especially* bad. 

My secondary concern is that I think the spillover effects here might go considerably beyond immediate household members. In response to your points;

1. Thanks, that makes sense to me! I do think there's some way in which this is an overestimate (aka maybe v young children are less affected by the death of a sibling). However, idk if this enough to compensate for not having accounted for non-household spillover effects; my sense is that the friends of the kid would be affected, plus other members of the village, parents who get rightly scared that their kid will fall ill, and so on. Aka I could see effects along the line of 'my childhood best friend died, this adverse childhood experience contributed to my adult battle with depression'.
2. That also makes sense to me, cheers. I don't have a strong sense either way on this.
3. This would make sense to me if it was adult versus adult deaths, but it seems worse to me for a parent to lose a kid (relative to counterfactual). I can see how this is a super thorny issue! Maybe it ameliorates the problem somewhat?

I do want to highlight the potential 'duration of effect' plus 'negative spillover might be higher than (positive) spillover effects from GD' issues because I think those might change the numbers around a fair bit. I.e. if we assume that effects last 10 years rather than 5 (and I see an argument that child bereavement could be like 20+) , and spillover is maybe 1.5X as big as assumed here, that would presumably make AMF 3X as good. 

Thanks for this post, fascinating stuff!

My quick-ish question: is it possible that you are underestimating the WELLBY effect of grief, for AMF? My understanding (from referring back to the 'elephant in the bednet' post, but totally possible that I've missed something) is that these estimates are coming from Oswald and Powdthavee (2008), and then assuming a 5 year duration from Clark et al. (2018). Hence getting an estimate of ~ 7 WELLBYs.

The reason I'm a little skeptical of this is first that it seems likely to me (disclaimer that I have not done a deep dive) that losing a child would increase the likelihood of depression and other mental illnesses, alongside other things like marriage disruption (e.g. Rogers et al. 2008, which highlights effects lasting to the 18 year mark). I don't think these effects will be accounted for by pulling out the estimate coming from Oswald & Powdthavee according to the Clark paper.

Along similar lines, I also think the spillover effects of AMF might be underestimated;  my intuition is that losing a child is inherently especially shocking, and that the spillover effects might  larger than the spillover effects from things like cash transfers/ therapy- e.g. everyone in the community feels sad (to some degree) about it.  Am I correct that the spillover for AMF is calculated only for family members, not for friends and other members of the community?

Interesting, thanks for sharing! I checked out the slides and am now curious about the cultural effects of Fox News...

Hi David, thanks making these points. I totally  agree that there's likely to be a lot of variation between campaigns, and that examining this is a critical step before making funding decisions- I don't think (for instance) we should just fund mass media campaigns in general. 

I did find it helpful to focus upon mass media campaigns (well, global health related mass media campaigns) as a whole to start with. This is because I think that there are methodological reasons to expect that the evidence for mass media will be somewhat weak (even if these interventions work) relative to the general standard of evidence that we tend to expect for global health interventions- namely, RCTs. This is because of problems in randomising, and of achieving sufficiently high power, for an RCT examining a mass media campaign. I think this factor is generally true of mass media campaigns (and perhaps not especially well-known), hence the fairly broad focus at the start of this report. 

I agree with you though that ascertaining which programs tend to work is hugely important. I've pointed to a few factors (cultural relevance, media coverage etc), but this section is currently pretty  introductory. The examples I've focused upon here are the ones where there is existing RCT evidence in LMICs (e.g. family planning is Glennerster et al., child survival from recognition of symptoms is Sarassat et al., HIV prevention is Banerjee et al.) Some things that stand out to me as being crucial (note that I'm focusing upon global health mass media campaigns in LMIC) include the communities at hand having the resources to successfully change their behavior,  there being a current 'information gap' that people are motivated to learn about (e.g. the Sarassat one focuses on getting parents to recognise particular symptoms of diseases that could effect their children, and the Glennerster one provides info about the availability and usage of modern contraceptives), cultural relevance (i.e. through the design of the media) and media coverage. 

Thanks Tyner! I was hoping someone might be aware of potential orgs :) I haven't checked those ones out yet– I will add them onto my list to check out.

Hm I don't think that follows from the review- I would ideally like more studies looking at whether fluoride can affect IQ (esp at high concentrations), but I don't think this should be the highest priority thing. 

I want to highlight that the 'low level evidence' refers to fluoride at high concentrations. As I've outlined above, I think that fluoride interventions should only be used in areas with low fluoride levels.  See the start of that review's discussion, where it reads 'This systematic review and meta-analysis gathered evidence showing that, following the WHO classification of low and high levels in the drinking water, exposure to low/adequate water F levels is not associated with any neurological damage, while exposure to high levels is. The level of evidence for this association, however, was considered very low.'

I could still see an argument to add in a risk factor to my CEA, but (bearing in mind that this is in a low fluoride area) I think this risk is sufficiently small that it is not worth including. For example, I haven't included a factor for 'not in pain = can go to school = higher IQ/ earnings' which I'd argue has more support behind it. Nonetheless, I will keep an open mind and watch out for any new studies about this.

Thank you Marshall! Definitely agree with you about the limitations of DALYs—as useful as they can be in some contexts—and the point that sugar taxes likely have benefits beyond oral health. I think sugar taxes (and maybe other regulation, like trans fat regulation) are likely to be impactful in part from having pretty broad-reaching benefits that aren't reflected in my CEA here (blood pressure/ cardiovascular health, obesity, oral health, etc etc). 

Thanks also for the note about the cause exploration prizes!  Unfortunately, I think this piece is too long (and now has already been published online)—so I don't think it's eligible (? not quite sure) but i'll check it out!

Hi Christian,

Thanks for this comment, I am happy someone drew attention to this!

I did check out various papers (such as the one you linked, and some other papers proposing a link between fluoride exposure and adhd). I didn't find them convincing enough to add in a non-monetary cost to fluoride (bear in mind that I also left out various potential net-benefits, such as increased attendance at school and work). 

To give a bit more detail (because I think this important), I found that the evidence linking fluoride to neurological outcomes was pretty low quality. I could only mainly find ecological studies, where i judge the risk of confounds to be very high- plus other issues that make me suspicious such as exclusion of outliers (without clear justification). That being said, I do think it's important to be cognisant of these theories, even if the available evidence is poor— I quite like this review, which basically argues that low to adequate levels of fluoride don't appear to be associated with any neurological conditions, but there is 'low level' evidence that they are at high concentrations.

To me, this gets at the point that fluoride should only be used in communities that have low levels of fluoride already— apart the speculation about neurological disorders, we know that fluoride can cause fluorosis  (weakening of tooth enamel) in levels with high levels of fluoride. I have put the 'costs' of fluoride at zero, but have highlighted in the report that I think these kinds of interventions should only be used in area with low fluoride (for instance, not areas with high levels of groundwater fluoride). In areas with high fluoride, I agree with you that there might be 'costs' to be accounted for .

Totally agree with you on the point about trust! I quite like the salt/ milk interventions since they are more 'opt in' than water fluoridation (aka you could just buy the other salt/ milk), as well as being more practical in areas with lower levels of piped water access. I'd hope that this would mean less pushback.

Yep! I do think flossing is good, but I suspect it's less impactful/ helpful than fluoride (especially fluoride added to water/ milk/ salt).

Thanks! I didn't especially look into tongue scraping, but I'll check it out a bit more. My general sense would be that it would be tricky to persuade people to do regularly, in comparison to something 'automatic' like fluoridated salt.